Smoking prevalence rates have continued to decline in the UK, with fewer young people starting to smoke and greater numbers of people quitting.1 Smoking has also continued to decline across all socioeconomic groups. However, those from the most disadvantaged groups, such as those presenting with multiple and severe mental illness and substance use comorbidities, present smoking prevalence rates that far exceed those of other groups.2–5
Smoking is extremely common among adults experiencing homelessness, with prevalence rates ranging from 57% to 82%;4 this is up to four times higher than the UK national average (15.1%).1
Smoking is related to premature death and disease, and quitting can have a substantial positive impact on reducing harm and increasing life-years.6 In smokers experiencing homelessness, tobacco-related disease has been cited as the second single cause of premature death and the single largest cause of death in those aged > 45 years.7 Smoking is particularly fatal among this population because of a higher incidence of respiratory infection and disease.8 These conditions are likely to be exacerbated because of a general likelihood of engaging in practices that increase the risk of developing respiratory infections, for example smoking discarded cigarettes and sharing cigarettes that act as a vessel for passing viral contaminants.9,10 Poor respiratory health is also likely to be aggravated by smoking unfiltered and illicit tobacco, dragging harder on cigarettes and taking longer deeper puffs.9 Beyond the health effects, smoking is also related to several social disadvantages; smokers experiencing homelessness are likely to engage in begging or ask strangers for cigarettes and are reported to spend up to one-third of their income on tobacco and cigarettes.11
The types of lives that smokers experiencing homelessness have mean that quitting smoking is not a high priority and is also often overlooked by those who support them.12 There is also some evidence that health and social care professionals are concerned that cessation will exacerbate mental illness and that taking something away, when many of these adults have so little, will be unfair or cruel.13 Although these concerns are understandable, a survey we conducted in 2018 of 286 smokers accessing homeless services in England and Scotland showed that 75% of smokers have some desire to quit smoking and 75% have some history of quitting; however, quit attempts are often unsupported by behavioural support or licensed nicotine medication, and last less than 24 hours.14
The UK has a clear goal of reducing the harms caused by tobacco smoking; central to this is the reduction in tobacco-related health inequalities by improving cessation rates. At present, however, smokers experiencing homelessness are not well represented in stop smoking services (SSSs) and cessation support is not mandatory in homeless centres. In the recent Tobacco Control Plan for England,15 the Department of Health and Social Care (DHSC) expresses its commitment to evidence-based innovations to support quitting and will seek to support smokers in adopting the use of less harmful nicotine products such as electronic cigarettes (ECs). Nevertheless, smoking cessation in the context of homelessness is underexplored in the UK. Our recent systematic review of 53 studies showed that only two cross-sectional studies had been conducted in the UK,4 of which one was conducted by our group.14 Trial evidence from the US shows that there is potential to support cessation in this group. For example, Okuyemi et al.16 measured the efficacy of motivational interviewing (MI) offered alongside licensed nicotine replacement therapies (NRTs) compared with NRTs alone. Using intention-to-treat (ITT) analysis, verified 7-day abstinence rates at week 26 were 9.3% for MI and NRTs, and 5.6% for NRTs alone (p = 0.15). To our knowledge, prior to the work presented here, there were no smoking cessation intervention studies in the UK. To reduce the burden of smoking among this population, more evidence of the efficacy of interventions is clearly required.
Our systematic review4 and public and patient involvement (PPI) work (conducted in 2017, with seven homeless centres, eight interviews from one major homeless charity and scoping data from 100 participants) helped to shape the design of this study. We were told that the multiple competing needs in this group meant that access to support needed to be made easy and appealing to provide the best chance of engagement. Thus, it was decided that the feasibility study should be embedded in centres that participants were already accessing. Our PPI work also suggested that ECs may be particularly appealing to smokers experiencing homelessness because (1) smokers in our scoping work were already experimenting with them, (2) they can be framed as a switch rather than a quit (which has connotations of loss), which has been highlighted as an issue of cessation, and (3) they can be offered at a location already being visited without a prescription, thus reducing the burden of making further appointments and removing a clinical approach. Taken together, the feedback was that ECs offer a pragmatic harm reduction approach to smoking cessation, and this is especially important when delivering interventions in the third sector, where substance harm reduction is already well established.
An individually randomised trial with allocation to one of two arms [ECs vs. usual care (UC)] was initially considered, but our PPI feedback (from staff and clients at homeless centres) strongly advised against this because of potential problems with compliance, contamination and issues of disharmony, for example resentment towards staff delivering the intervention in which one person had received an EC and another had not. Contamination, harmony and protection of staff were important; therefore, our decision was to opt for a feasibility cluster trial.
Here we present a pragmatic four-centre cluster feasibility study exploring the uptake and use of ECs by smokers accessing homeless support services. The overall purpose of this research was to evaluate the feasibility of supplying free EC starter kits for smoking cessation to smokers experiencing homelessness at a place that they were already accessing. The UC arm received standard existing treatment: advice to quit, an adapted NHS Choices fact sheet for smoking cessation and signposting to the local SSS, which offers weekly behavioural support and a choice of NRT or varenicline. The EC arm received a starter kit, a 4 weeks’ supply of e-liquid and a fact sheet.